When it comes to matters of the heart, millions of Indians around the globe immediately think of the hundreds of Bollywood movies and unforgettable songs! However, when it comes to matters of the heart as cardiologists see them, it is a different story and an alarming one! Heart disease is now the number one killer in India. A 2016 study published in the journal Circulation, states that in India 52% of deaths occur due to cardiovascular disease (CVD) in people before age 70. In comparison, in Western Europe this percentage is about 23%.
Not only has the incidence of heart attacks increased substantially, studies show that heart disease in the Indian population affects younger people! I personally know some friends who suffered from a heart attack in their mid 30’s and 40’s. These young people I know are not smokers, physically active and they were not seriously overweight or obese, and did not have any underlying heart conditions. Furthermore, the risk of dying from heart attack is higher for a person of Indian origin than for a Caucasian. Cardiologists are alarmed as they see beginning of accumulation of plaque – fatty deposits – inside the arteries of fifteen year olds! Autopsies performed on young soldiers (that unfortunately died in war or other causes) also show evidence of heart disease.
Vascular Age vs. Chronological Age
Thomas Sydenham, MD, (English Physician, 1624-1689) famously quoted “A man is as old as his arteries.” This is in line with what cardiologists refer to as the concept of vascular age. Your vascular age is different from your chronological age. A 35-year-old man, a smoker and a diabetic with high blood pressure, has arteries that are of effectively that of a 76-year old. A 30-year-old woman with similar risk factors has arteries that are effectively that of a 80-year old! Fortunately, we can turn the clock back on the vascular age. Read on.
Underlying Cause of CVD?
In a 2013 paper published in the Journal of American College of Cardiology, reported an alarmingly high increase in the incidence of diabetes mellitus (DM) and CVD. In fact, India is now considered to be the “Diabetes Capital of the World”! He stated that an explosive increase in diabetes incidence in Indians in India and immigrant populations is causing significant increases in coronary heart disease (CHD) and stroke.
So going back to the high prevalence of heart disease, its spread to a younger population and the higher levels of fatality specifically in the Indian population, I started to wonder as to what is going on here? Why are Indians, compared to other ethnic groups, at such an elevated risk for heart disease? Is it just karma? Are we just born with bad genes? Or is it that our lifestyle and culture (or both) increase this risk? How can a large population in India be vegetarian and at the same time have such a high risk for heart disease? Is it that India is a relatively poor nation where access to medicines to treat diabetes and heart disease is severely limited? How are diabetes, stroke, and cardiovascular disease related? What we can do for ourselves and our families and communities to increase our heart health?
Q&A With Dr. Indu Poornima
Recently, I had the privilege of speaking with Dr. Indu Poornima, a renowned and practicing cardiologist in Pittsburgh to discuss these very questions. I am thankful to Dr. Poornima for her time. She spoke to me not only as an eminent cardiologist but also as someone who understands the culture and unique challenges Indians face back home and abroad.
Dr. Poornima is the Medical Director, Nuclear Cardiology, and also the Director, Women’s Heart Center at the Allegheny General Hospital in Pittsburgh. Dr. Poornima is also a faculty member at Temple University’s School of Medicine. She received her medical degree from Stanley Medical College in India, followed by her residency at Wayne State University Health Center in Detroit, Michigan, and fellowships at both Medical College of Wisconsin and Mayo School of Graduate Medical Education in Rochester, Minnesota. Dr. Poornima is a leader in many community health-based programs and events aimed specifically at promoting heart health for women such as the Go Red for women by the American Heart Association.
Q. What are the risk factors for someone developing heart disease?
A. A very important risk factor for heart disease is diabetes. If you are a diabetic, the chances of having a heart attack are 3 to 4 times higher than that of a person who does not have diabetes. A diabetic person has high levels of sugar in their blood. This high sugar level in blood vessels, over time, will damage the blood vessels leading to fatty deposits, affecting blood flow. This increases the chance of clogging and hardening of blood vessels (atherosclerosis). Another factor is central obesity which is measured by your waist-to-hip ratio. Diabetes in Indians is usually accompanied by higher level of triglycerides and low levels of good (HDL) cholesterol which further increase the risk. High blood pressure is an additional risk factor that is frequently present among Indians.
Q. Among the above risk factors, which specifically is the biggest one for people of Indian origin?
A. I would definitely say diabetes is the biggest risk factor for Indians and even for others. If you compare Indians with other ethnic groups such as Caucasians, Latinos or African-Americans, the incidence of other factors such as obesity, high blood pressure, and low HDL is similar across different groups. However, the incidence of diabetes is much higher in Indians.
Q. If diabetes is a risk factor for heart disease is it a risk factor for stroke as well?
A. Yes absolutely! Diabetes is a risk factor for both stroke and heart disease. The same kind of damage to blood vessels that would restrict blood flow to the heart also restricts blood flow to the brain. This would cause a stroke.
Q. If diabetes is such an important risk factor for heart disease and stroke, could controlling diabetes lead to a decrease in risk for a heart attack or a stroke?
A. This is key. To prevent heart disease it is important to control diabetes, which is the single most important risk factor especially for Indians. First, increased physical activity (PA) is very important. At a cellular level, physical activity increases what is called as AMP kinease (AMPK) enzyme which helps use the sugar (glucose) in the blood. Less sugar in the blood means less stress and damage to blood vessels. This means less chance of forming fatty deposits and less risk of heart disease and also less chances of a stroke!
Type II diabetes, which is most common, can be controlled if a person loses substantial amount of weight. Proper nutrition also plays an important role in lowering blood sugar. For some people, exercise and diet may not be sufficient; in such cases, drugs are often the first step in treating diabetes.
Q. You mentioned physical activity, can you elaborate?
A. Staying physically active is very important. It reduces the incidence of so many diseases like CVD, diabetes, stroke, dementia, and different forms of cancer. I often write a real physical activity prescription for the patients similar to what they are used to with medications. It is indeed the cheapest and most effective treatment! This seems to sink in better when I write it down than just telling a patient verbally. It is important to note that the way exercise works is very similar to the way the drug Metformin works. Physical activity causes increase in the AMPK enzyme and this results in the conversion of blood sugar (glucose) into energy for the body. The nice thing with exercise is that there are some great bonus effects! These include increased endurance, greater body tone, reduction of stress etc.
Q. As a follow-up, is there a preference on type of exercise aerobic or strength building?
A. For cardiovascular disease risk reduction, aerobic exercise is better. Any activity such as brisk walking, swimming, bicycling is really good. The recommendation is at least 30 minutes of moderate intensity of physical activity every day for five days in a week. Strength training is also important to build muscle mass. It is important to note that strength training feeds into aerobic training. If you have stronger muscles, you can do better with aerobic activities.
Q. Many people say they don’t have access to expensive gyms or equipment, very often the weather is not good, and people are so busy….
A. To be physically active, access to expensive gyms or fitness equipment is not needed. You can walk each day in your neighborhood or in a park nearby. Going up and down the stairs in your house or a shopping center is also a simple and effective aerobic activity. Very often communities have fitness centers, swimming pools that could be more affordable for the entire family. They also offer classes that could be fun. Most important is for you and your family to commit to physical activity.
Q. Going back to the remarkable increase seen in heart disease in Indians, what do you think are the reasons? Is it that we have bad genes or is it lifestyle?
A. The remarkable increase in heart disease in Indians appears to be largely driven by lifestyle. There is an underlying genetic component and it’s hard to separate the genetic and environmental (lifestyle, food, smoking etc.) components. We do have genes that make us more prone to abdominal obesity i.e. Indians tend to put on belly fat more easily. Our genes also evolved to deal with cyclical famines. So the bodies learned how to store every bit of food consumed to fight starvation. Now, even when there are no famines and plenty of food around, we still store excess calories consumed as fat. This is indeed a risk factor for CVD. However, the reason I say lifestyle plays a dominant role because it’s only in the past twenty years or so that we have seen this explosive increase in the number of people with diabetes and pre-diabetes, which in turn leads to a higher likelihood of heart attacks and strokes. If it were just genetic, we would not have seen a dramatic increase like this because our genes have not changed for thousands of years.
Q. What specifically are the lifestyles Indians have, that contribute to the increase the risks for heart disease?
A. Main risk factors for Indians stem from diet, desk jobs that require less physical activity, and smoking. Indian diets tend to be high in simple carbohydrates like rice, sugary desserts and salt. High blood pressure is a risk factor for heart disease, stroke and congestive heart failure. The risk of heart disease is increased by four times for a person that has diabetes and high blood pressure.
Socioeconomic factors also play a role. Very often, conditions like diabetes are not diagnosed. Even when they are, many people cannot afford medications and stop using them after some time. People who can afford and use medications, incorrectly think they can then go on to eat anything they want and they don’t need to exercise! Our cultural ways also play a role. For example, in many families, women are not encouraged to engage in physical activities like running, walking or swimming. Although women in India have traditionally been very active doing household chores, these activities are limited these days due to apartment dwelling, increased availability of fast foods and sedentary working conditions. As you may have heard, “sitting is the new smoking”. This means if you are sitting around most of the time, your risk for heart disease is increased by the same amount as it would if you were smoking.
Q. What about smoking? Are the new e-cigarettes any safer?
A. Smoking is another important risk factor for heart disease as well as for cancer and other diseases. Even in rural villages of India, the availability of cheap cigarettes (known as beedis) has increased rates of heart disease even in the lower socioeconomic classes. The new e-cigarettes are being touted as a safe alternative to traditional cigarettes. However there are no good, long-term studies done to assess their safety. Some of my patients have used e-cigarettes for a short period of time in order to quit smoking and this has been reasonably effective. It is important to recognize that even e-cigarettes contain varying amounts of nicotine and hence are not entirely a safe alternative. In fact, we are seeing an increasing use of e-cigarettes among teens and young adults in the US and that is certainly alarming.
Q. We have a large percentage of people that are vegetarians, why is the risk for heart disease so high?
A. This is known as the South Asian paradox. Indian vegetarian diet is still very high in carbohydrates and makes use of fried food, high salt, and sugars from deserts and is not necessarily very healthy. On the other hand, vegetarian diet in the United States tends to be healthier, with more fruits and vegetables (that are not fried or cooked in oil), more whole grains etc. The healthiest diet that can actually lead to a decrease in cardiovascular disease is what is called the Mediterranean diet, which is widely consumed in southern Europe. This is primarily vegetarian and contains a good mix of fruits, nuts, vegetables and some carbohydrates along with seafood in moderation.
The incidence of heart disease for Indians both vegetarian and non-vegetarian is about the same. In the United States vegetarians have a lower incidence of heart disease compared to non-vegetarians. I always tell patients to eat much more fresh fruits and vegetables. In India we have access to fresh fruits and vegetables but the issue is the way they are consumed (fried versus fresh).
Q. Any final thoughts?
A. Heart disease is no longer a disease of the old. There is evidence that shows plaque formation starts in children that are as young as 15. Prevention is the key. Once you sustain a heart attack or stroke, your lifetime risk of having more cardiovascular adverse events is high. Hence anything you can do from a lifestyle perspective or with medications to prevent that first event, should be the goal. Get moving, eat right, stop smoking, and stress less!
For additional information, check out Cadi Research Foundation.